Plan Materials and Resources

Member Materials

2021 Annual Notice of Changes (ANOC) English Español 中文 pdf icon
2021 Summary of Benefits English Español 中文 pdf icon
2021 Evidence of Coverage English Español 中文 pdf icon
2021 Provider and Pharmacy Directory Bronx Brooklyn Manhattan Queens pdf icon
2021 Formulary English Español 中文 pdf icon
2021 Extra Help Premium Summary Table English Español 中文 pdf icon
Multi-language Insert English Español 中文 Creole Русский Italiano 한국 pdf icon
Enrollment Form English Español 中文 pdf icon
Prescription Drug Claim Form English pdf icon
Appointment of Representative Form English Español pdf icon
Health Care Proxy Form & Information* English Español 中文 Creole Русский Italiano 한국 pdf icon
Part D Coverage Determination Form English pdf icon
Member Reimbursement Form English (coming soon)
Part D Coverage Redetermination Form English Español 中文 pdf icon
Prescription Drug Mail Order Form English pdf icon
Privacy Notice English pdf icon
Notice of Non-Discrimination English Español 中文 Creole Русский Italiano 한국 pdf icon
2021 Medicare Star Ratings English Español 中文 Русский pdf icon

Member Resources